Charting E/M Audits, a self-paced continuing education course on CD, offers comprehensive information on E/M documentation guidelines and code usage, and elaborates on how to audit services before they are billed, after they are billed, or how to focus the audit to target specific service areas. The course provides a comparison of the 1995 and 1997 E/M documentation guidelines and discusses the finer points of auditing with 1995 or 1997 rules.

Charting E/M Audits first reviews E/M services, the medical record, and the ABN, then uses that information and case studies to illustrate E/M auditing.

This course is available in the traditional CD-ROM media, or our exclusive Cloud-CD™ format. With Cloud-CD™ format, your computer won’t need a CD/DVD drive to run the course, but you will need access to the Internet. The image of the CD is stored “in the cloud”, so you can access course content using a browser on your system. Click here for more information on Cloud-CD.

The self-paced nature of the course allows you to work at your own pace. This is also an excellent way to satisfy the continuing education provision of the compliance plan of a physician practice or third party billing firm.

This course has been pre-approved for 11.0 Continuing Education Units from the AAPC. CEUs can be split between Core (CPC, CPC-H, CPC-P, CPB, CPPM) and all specialty credentials except CPCO, CASCC, CIRCC. For a reasonable expense, you’ll be able to tune up your knowledge and fulfill a good portion of your annual CEU requirement!

Here’s a sampling of what Charting E/M Audits covers:

Chapter 1 – E/M Services

Documentation of E/M Services

Quantity vs. quality of documentation

E/M code selection process

Key Components: an overview

History (and its components)

Exam (and its levels)

Medical Decision Making (and its complexities)

Pulling key components together to arrive at level of service and code selection

Chapter 2 – The Medical Record

Necessary elements that make up a complete medical record

Purpose of a complete medical record

What elements 1995 and 1997 guidelines agree on that make up a medical record

Typical elements of a medical record reflect a specific patient population

Chapter 3 – The ABN

ABN purpose

When to use the ABN

Who receives the ABN

Valid delivery of the ABN

Triggering an ABN

Documentation of ABN activities

Chapter 4 – About the Audit

Auditing and the electronic health records (EHR)

Reasons for doing and audit

Common errors found in a medical record

Review of the three types of audits

Chapter 5 – What’s in an Audit

Deciding the purpose and scope of the audit

Two steps to further focus an audit

Review of specific areas to ensure a complete medical record

Review certain types of forms, requirements, and information for completeness of the medical record

Chapter 6 – Audit Process

Six stages of an audit

Deciding on audit tools

Comparing information documented to what was coded

Presenting problems uncovered in an audit

Types of education, continuing education, and training for weak areas found in an audit

Summary reports

Chapter 7 – 1995 vs. 1997 Guidelines

Comparison of the 1995 vs. 1997 guidelines

Focused discussion where specifically 1995 and 1997 guidelines differ

Discussion of the HPI, Exam, MDM, and Risk

Bullet system for documentation elements

Point system for patient problem, and medical data review

Key components of E/M will be tied into auditing these types of services

To run Charting E/M Audits on your computer, the CD-ROM option requires a PC with Microsoft Windows 7, 8, or later, and a CD-ROM drive. The Cloud-CD™ option is compatible with either an Apple Mac or a Windows PC.

Make your selection below. Additional user licenses can be added when you get to the shopping cart.

AAPC/AHIMA member price for Cloud-CD™ version (Internet access to course content): $245, no S/H, but NYS sales tax if applicable.

Additional users: For this course, we offer user licenses for additional users sharing the same CD, for $75 each additional user. Must be purchased at the same time as the CD. A great way for significant savings when multiple users can share the same CD.